Performance by hospitals

The National Health Performance Authority has released several reports in the last few weeks, looking at how hospitals perform. The latest is on cancer surgery waiting times which shows significant variations and names some hospitals at the low performance end.

Transcript

Norman Swan: Hello and welcome to the Health Report with me, Norman Swan.

Today, critical information for you and me as consumers, about our $145 billion a year health system, including the benefits that can come from shining a light on the performance of hospitals and health professionals, such as fewer people dying unnecessarily after surgery.

A one-stop shop for men to receive prompt, efficient diagnostic tests for prostate cancer.

And according to a report released last week, there's significant and troubling variation in waiting times for common cancer surgery across Australia. In the case of waiting times for lung cancer—a rapidly progressing disease—the range is from four days to 43, with some major teaching hospitals not doing well at all.

The data come from the National Health Performance Authority who've also recently released information on hospital admissions for a host of conditions that could have been avoided.

Diane Watson is the Authority's chief executive.

Diane Watson: We were established to report nationally on the comparable performance of healthcare organisations, both in the hospital sector and primary care sector.

Norman Swan: And is this based on what are called the hospital agreements, the health and hospital agreements whereby the federal government has an argy-bargy with the states and territories about what performance they are going to get for their money?

Diane Watson: Yes, the Council of Australian Governments has agreed on 17 indicators of hospital performance, and almost 30 or just over 30 indicators of healthy communities that we'll be reporting on regularly.

Norman Swan: And what we are talking about today are part of those indicators?

Diane Watson: Yes, we've released a few reports recently that are of high interest to people, most recently a report on wait times for cancer surgeries for three of the most common malignant cancers.

Norman Swan: Amazing variations here. Do we know what the acceptable performance is in each of these cancers?

Diane Watson: Well, importantly, this report that we released, for the very first time we can compare performance of hospitals across similar hospitals for these important cancers, and there is no nationally agreed wait-time benchmark in Australia for these cancers. So what we've done is we looked at the comparable performance of hospitals.

Norman Swan: But you don't really know what the right performance level is.

Diane Watson: Well, we do find in Australia 90% of patients are seen within 30 days, 97% within 45 days. So we've used that as a point of reference.

Norman Swan: And there's really quite significant variation though, so that's a good-news story, that we are performing not badly, if indeed that's okay. It might be okay except that there is a lot of variation in outcome in bowel cancer and in lung cancer across the nation, unacceptable variation between the best and the worst. So what you're measuring is a process outcome, how soon you get surgery after diagnosis.

Diane Watson: That's right, very important that people receive timely care for these types of cancers. For malignant breast, bowel and lung cancer, surgery is a mainstay course of treatment. We measure the time between when there has been a decision to implement the surgery and when the surgery has occurred, and we do see that there are big differences across some of the hospitals; a vast majority of hospitals seeing patients within 30 days of that decision to treat, remaining hospitals within 35 days. A few hospitals, however, are taking longer than that time.

Norman Swan: So with bowel cancer, in theory a curable cancer if you get to it in time, Princess Alexandra Hospital in Queensland, Fremantle Hospital in Western Australia, they are up to 45 days, they are amongst the poorest performing hospitals in Australia, at least in metropolitan hospitals.

Diane Watson: Yes. So of the patients who have waited longer than 45 days we see that there are more than 380 of them, they are spread across a number of hospitals. But as you have mentioned, there are some hospitals where we see a lower percent of patients being seen within 45 days of a decision to treat for these important cancers.

Norman Swan: So, let's go to lung cancer now where the variation could be really very significant, because this is a cancer that moves very quickly. And again, you had major hospitals like Liverpool in New South Wales and Princess Alexandra performing not very well in terms of the lowest percentage being operated on within 30 days, Liverpool still performing badly at 45 days, and St George in New South Wales performing badly in 45 days. So these are quite troubling statistics of something that should be jumped on. By the time they are seen, the lung cancer could have spread and they become inoperable.

Diane Watson: Remember, these patients will be seen by clinicians right throughout their course of treatment. What we are measuring today is the length of time between a decision to receive surgery and receipt of that surgery. Sometimes in that period of time there will be some need for other kinds of interventions where they won't be able to receive surgery in that time. We subtract that amount of time. So these are the number of days between a decision to conduct the surgery and when surgery is…

Norman Swan: So you are allowing for variations in care. So some hospitals might give them chemotherapy before surgery, for example.

Diane Watson: Yes, and after the chemo is done and they are ready for care, these are the percentage of patients and the amount of time it takes to receive the surgery, that they were ready for care and waiting for surgery.

Norman Swan: So you've allowed for that?

Diane Watson: That's correct.

Norman Swan: No doubt these hospitals will be arcing back at you, they'll be saying, you know, 'you've got it wrong, your data is lousy, your definitions are crap, we're not really that bad'. That's what always happens. They've obviously seen this data before you released them. What did they say?

Diane Watson: We provide this information. Again, brand-new information where hospitals can compare themselves right across the country. They can’t compare themselves to local hospitals with their colleagues or sometimes even within a state, naturally, but for the first time they are able to benchmark themselves right across the country. Now, we give the information to the hospitals and to the health system managers, the states and territories, a couple of weeks before we release the report so they can do any assessments that they need to of the data. Then the report is released, as we have done.

Norman Swan: So what do they tell you is the reason? Because they will say, oh, our patients are different from the average, we see the hardest patients, or the hardest patients go to Royal Prince Alfred in Sydney and we don't get them, so we get patients who can wait.

Diane Watson: Two things are important here, one is that we had an advisory committee of clinicians and surgeons who conduct these types of operations and they have helped define for us the specific types of patients and the specific types of procedures that these patients underwent, because it is really important when comparing hospitals to be comparing similar types of patients.

Norman Swan: So what do you expect hospitals to do with this information? I mean, some of the people who run these hospitals, I'll pick up Princess Alexandra Hospital in Queensland, the person who runs the Metro South Hospital and Health Service south of the river in Brisbane is very competitive, he wouldn't like the fact that Princess Alexandra is not performing well in a couple of areas. What do you expect them to do?

Diane Watson: It's great that they are competitive. This works to our advantage. When given comparable information for the first time about their performance right across the nation we expect that they will learn from their colleagues and to emulate care that is received in quicker time in other locations. We do know internationally that when comparable performance of hospitals is made public, that we see acceleration of improvements in care from that information.

Norman Swan: So they would just go into an analytic process; what's happening with their cancer teams, where is it falling down, people slipping between the cracks…

Diane Watson: Right, it's the continuous pursuit of quality improvement that this information is expected to accelerate.

Norman Swan: Let's look at another area that you've been looking at which is even more astounding in its variation, and this is the extent of avoidable hospital admissions…so in other words, hospital admissions that need not occur, by a Medicare local. In other words, Medicare locals are these organisations that are supposed to organise general practice and other forms of medical care or healthcare in the community and they cover geographic areas. And you've covered this by Medicare locals. So first of all, what sort of conditions are ones where the hospital admission is potentially avoidable?

Diane Watson: This report on avoidable admissions looks at conditions under which we would expect that best care in the community can help avoid admission to hospital. These are hospitalisations for conditions such as asthma, diabetes, hypertension. It doesn't mean on the day that people showed up at the hospital that they didn't need to be admitted, but we do know that with best care in the community we can avoid a situation where they need to go to hospital for care.

Norman Swan: And this is about 10% of all bed days in Australia.

Diane Watson: That's right, this adds up to about 10% of bed days. A bed day is a bed that's available for a patient on a day. So about 10% of bed days in Australia is accounted for conditions that we know that best care in the community might have helped us avoid the hospitalisation.

Norman Swan: Which is why you do it by Medicare local because the implication here is if they've been well cared for at home, they might not have gone acute and therefore needed to be in the ambulance going to the emergency department.

Diane Watson: That's right. So we have measured this across just over 60 regions in the country, and for even smaller level 300 units of geography that add up to the country of Australia. So we can identify the local areas that have higher rates and therefore target interventions to reduce rates in those local communities.

Norman Swan: So there's about a 60% variation in the metropolitan Medicare locals, with Northern Sydney doing best at 2,000 hospitalisations per 100,000, and south-eastern Melbourne, actually quite similar demographically, well-off areas, they are not doing as well, 3,000. So, paradoxically, two ends of the scale with quite rich populations, well covered by GPs, with a very big difference.

Diane Watson: Lots of options in metropolitan communities. So in our reports, as I mentioned, we released for 60 areas, we put them into peer groups, so we have metropolitan high income, metropolitan middle income, metropolitan low income, we compared by regions at varying socio-economic circumstance and health, and same with rural communities. It's really interesting to focus on that major metropolitan, to look at avoidable admits to hospital because it is in the major metropolitan areas that we have a number of options to be providing care in the community versus in a hospital, and we do see important differences in avoidable admits to hospital. As you mentioned, it can be 60% higher in some communities relative to others, in our major metropolitan communities.

Norman Swan: And the difference in rural areas is double, so it's 100% difference between areas…

Diane Watson: That's right, twice as likely in some communities than in others to have avoidable admits to hospital.

Norman Swan: And in general even the best performer in a rural area was still not as good as a metropolitan area, which shows there aren't as many options, but the worst, which was greater south coast Victoria, it was 4,000. So again, 30% higher.

Diane Watson: Big differences, big differences. I think what is really unique and important about these reports is that we have known these numbers and calculated them before for all of Australia and for the states, but if you got your number in your state and you found that it was high, where do you start? So what's new and unique about this report is that it takes information right down to local areas. Like I mentioned, 600 areas, and then we also provide analysis to 300 local communities…

Norman Swan: Where the difference is seven-fold, 700% difference.

Diane Watson: Exactly, seven times higher in some local communities than others. And what this really does is help people in our community identify the local community that needs our support most to be able to avoid admissions to hospital.

Norman Swan: And is there any sense from this of any other data why this variation is occurring? I mean, in rural areas there is a shortage of GPs, in some areas, not all, GPs generally don't bulk bill so there might be a cost involved. Do we know what the story is?

Diane Watson: Because this is the first report we haven't yet investigated in depth as to why this occurs, but we have taken an important step. One is that we provided the information targeted at very local communities, and on our website, My Healthy Communities website, there is a diagnostic profile for each of those local Medicare locals. So in 60 communities in the country we have identified rates where they are very high and what are the diagnostic conditions, is it asthma, is it diabetes or a combination of those conditions. People in the community know what communities to target and what are the conditions that are bringing those people to hospital.

Norman Swan: And do the conditions vary much?

Diane Watson: Yes, they do. One of the things that we are finding across all of our reports this year is that each community has its local health profile and its local healthcare use profile. And so by creating the unique profile for that local community they can identify priorities for that community in terms of interventions to promote health and keep people healthy and out of hospital.

Norman Swan: And of course in a small area, particularly in the country, it could be something as simple as diabetes is doing well because you've got a really good diabetes nurse, and asthma is not doing well because there is nobody out there doing stuff with asthma.

Diane Watson: It's very true, very true, and at the same time we have identified areas in the country, for example, where gangrene rates are very high…

Norman Swan: So diabetic feet.

Diane Watson: Diabetic feet, this is a process in which there is a long lag time in which we can have multiple interventions to prevent that very poor health state that requires someone to go to hospital, and indeed people don't want to be that sick.

Norman Swan: So again, this is not about blame, it's about Medicare locals and the hospitals getting together to analyse why it is in our area…

Diane Watson: It's about putting information in the hands of people who can do the most about it, to tailor interventions for their local community or their hospital to be able to improve care.

Norman Swan: So within your reporting system, is there an expectation of how quickly you expect people to perform so that the next time you do it they are better?

Diane Watson: We will be reporting each year, and for some types of information even more frequently, on the progress of change that we should expect to see and hope to see. We have done this already, just being here for one year, our first report was on the length of time that people are spending in emergency departments because there is a target to have very few patients waiting longer than four hours.

Norman Swan: It's called the NEAT target.

Diane Watson: That's correct, the National Emergency Access Target. We do see from our first report until today there has been tremendous improvements in some emergency departments, and in fact the biggest gains are in the emergency departments that had the poorest performance at the beginning of the period.

Norman Swan: How are the politics going to run? Because in the past when you've had national organisations such as yourself, the temptation in the system, in this fragmented health system that we've got, is that when the states and the territories get together with the Commonwealth they shoot the messenger. Rather than looking at themselves, rather than thinking through 'how do I solve this problem', they say it's the National Health Performance Authority, let's blow it out of the water. And I've already heard the tom-toms running; why have we got this National Health Performance Authority, it's yet another agency. And the people are muttering, well, we should get rid of it. Do you think you are going to survive the bad news?

Diane Watson: Oh I certainly hope so. We have been providing fantastic information to help focus and inform local efforts to improve care. What's unique about our organisation is we have a governance model that allows us and encourages independent impartial information. We have no, for example, government reps on our board. We also, through legislation, are empowered to report on high and low performing organisations independently, that's what's new.

Norman Swan: And that's what we all hope will survive.

Diane Watson: And that's what we hope is preserved. This information we've already seen being provided in the hands of local communities and local hospitals to target efforts to improve care, we are already seeing demonstrated improvements. We have already seen tremendous uptake of a report that we released on immunisation rates in the local communities. And in both those areas, emergency departments and immunisation rates, we have been tracking historically rates at state level, and it camouflages high performers and low performers, it has camouflaged historically local communities where we see low rates of immunisation. By revealing that information, as we have done this year with immunisation, we have already seen legislative changes in New South Wales, for example. We will be tracking immunisation rates and we will be reporting later on this year to see to see if that huge community engagement process around the rates of immunisation in the local community indeed has lifted rates in local areas. We'll be seeing if that has occurred this year.

Norman Swan: Diane Watson, who runs the National Health Performance Authority, and we'll have links to their reports on our website, which is the Health Report, and we are here on RN with me, Norman Swan.